Why was the Patient Centered Primary Care Medical Home unsuccessful? It was not really implemented!

 

In a recent post on the blog of the Medical Care section of the American Public Health Association (APHA), Dr. Gregory Stevens wrote Is something going wrong with the Patient-Centered Medical Home? His concern was engendered by the results of a study in the journal Medical Care (also published by the Medical Care section) by Colasurdo, Pizzimenti, et al., “The Transforming Outcomes for Patients Through Medical Home Evaluation and reDesign (TOPMED) Cluster Randomized Controlled Trial: Cost and Utilization Results”. This study examined a sample of practices implementing the PCMH model and showed varied results. The trends were toward more emergency visits, fewer hospitalizations, and unchanged costs. This was not supposed to be the result, and was a disappointment to Dr. Stevens, especially given that he was mentored by Dr. Barbara Starfield, whose research documented the beneficial impact of Primary Care on quality of care, cost, and population health.

First, some effort to clarify the terms; PCMH stands for both Primary Care Medical Home (as it generally does in the settings studied by Colasurdo, et al.), as well as Patient-Centered Medical Home, which is the term Dr. Stevens uses (actually, Colasurdo. uses both. The fact that both Primary Care and Patient Centered have the same initials is kind of cool, but it can be confusing, Indeed, in 2006 an organization called the Patient-Centered Primary Care Collaborative (PCPCC) was created. The impetus came from Dr. Paul Grundy, a physician and former VP of IBM who had recognized that the medical care costs paid by IBM in countries with a strong primary care base were much lower, even when controlling for the fact that many of those countries had national health insurance (because, in either case, IBM was paying the costs). This group, now renamed the Primary Care Collaborative, counts as members providers (both physicians and health systems), insurers, employers, pharmaceutical companies, patient-advocacy groups, and others. At the time of its creation, it was considered potentially revolutionary; with all of these major groups ostensibly buying into the benefits of primary care, the primary care specialties (family medicine, general internal medicine, general pediatrics) thought that there might finally be adequate recognition of their work. So, while of course being “Patient-Centered” is very important, it is the “Primary Care” that characterized these practice changes.

They were optimistic, but, unsurprisingly, overly optimistic. While having all those players in the PCPCC seemed like a good idea, but their agendas are not necessarily aligned with those of primary care; they can be summarized as “make money”. So they loved the “at lower cost” piece, and kind of liked the idea that maybe there was something magic in primary care that could lead to higher quality and greater patient satisfaction while spending less. Of course, it is not magic, but requires a coherent strategy to implement a structure in which the strengths of primary care were realized.

Dr. Starfield identified these strengths as the “4 Cs” of primary care:

• first-Contact care

• longitudinal Continuity over time

• Comprehensiveness, with capacity to manage majority of health

problems, and

• Coordination of care with other parts of the health care system

Starfield states ‘A primary care physician practices first-contact, comprehensive and coordinated care within the context of long-term person-focused relationships.’ (Starfield B, Oliver T. Primary care in the United States and its precarious future. Health & social care in the community. 1999;7(5):315-323). These characteristics allow the identification of which specialties are actually primary care (family medicine, general internal medicine, general pediatrics, geriatrics) and which are not. For example, it does not include either emergency medicine (yes for first-contact, no for continuity) or obstetrics-gynecology (many women’s primary physician, but scarcely comprehensive, dealing only with the reproductive tract).

The term PCMH (whichever “PC” you choose, or both) has not much been used lately. The more recent formulation has been the “Triple Aim” of higher quality, greater patient satisfaction, and lower cost, even more recently expanded to include physician (or clinician) satisfaction and lower rates of burnout to make it the “Quadruple Aim”. But, according to the study by Colarsudo and summarized by Stevens, it hasn’t worked. Why?

There were two major flaws in the implementation of the PCMH (or, if you like, PCPCMH). The first is a national issue which needs to be addressed as a baseline, something which is necessary if not sufficient to ensure quality, is that the US does not have a universal health insurance system. (And, of course, everyone is not covered by IBM.) That means that whatever the benefits of primary care are (and I believe they are enormous), they will not be realized by the entire population, The fact that so many people have no insurance or have inadequate insurance makes the whole enterprise of trying to reform the American health system in any significant way impossible. When so many people haven’t got the money to access medical care (and in this regard, having poor quality insurance, with high copays and deductibles, is often worse than no insurance, despite what advocates for ACA / Obamacare claimed), they delay care. They not only end up in the emergency room rather than a primary care office, they end up there when they are much sicker, more likely to require hospitalization, and more difficult to treat and cure. Until this is addressed, any attempt to make any kind of major reform that is intended to improve the health of the overall population is doomed.

 

The other major flaw in implementing the PCMH was that the power players in US healthcare, the health systems and insurance companies, decided to try to realize the lower cost on the front end. They did not make the investments needed to ensure that primary care could function effectively to achieve what should be considered the two truly important aims, higher quality and greater patient satisfaction. As in every endeavor that seeks to make – or save – money, course upfront investment was necessary, but shockingly little was invested. For starters, there was a need for a lot more primary care clinicians than we currently have in the US to be able to ensure that people can have access, and that doctors have enough time with their patients and are not being asked to churn so many patients through. Without this you won’t be able to realize the long-term benefits of primary care identified by Dr. Starfield and others. You won’t get quality or patient satisfaction if people are being rushed through like cattle.

For there to be enough primary care physicians and other clinicians you have to start with paying them more without concomitantly asking them to “produce” more. Too few medical students are entering primary care, seeing both the heavy workload and relatively lower pay (also a marker of lower status). Concomitantly, to the degree that achieving these goals can be facilitated by other staff doing much of the work to maintain registries, remind patients of preventive care, etc., those staff have to be hired and trained. The wrong way to do it is how it has been done: requiring the clinician, rather than other staff, to enter all this data into the Electronic Health Record, using the most expensive and highly-trained members of the team to spend their time doing secretarial work instead of seeing patients. Indeed, primary care clinicians are now finding that they often spend more time charting than interacting with patients; this is a recipe for them to burn out and leave, not to increase either their satisfaction or that of their patients.

The solutions are clear – take care of the problems. More students need to choose to enter primary care, and this means that primary care clinicians have to be paid as much as other specialists (whether by paying PC more or paying the others less) and have workloads that encourage them to spend as much time as necessary with each patient listen to them, address their problems, and communicate effectively; that is, to provide them with quality care, to be able to deliver on the potential benefits of primary care. The cost savings come at the back end, from fewer unnecessary referrals to other specialists, from fewer emergency visits, and fewer hospitalizations. But they come after the necessary investments have been made and the systems have time to adjust. As in any other industry you cannot take your profit before you have produced your product.

And, of course, we need to ensure that everyone is insured, and well-insured. The best way to do this is to have everyone in the same insurance program, with the same benefits. Medicare for All. Everybody in, nobody out.

Cost of health care increases poverty around the world, and in the US

The title of the press release from the World Bank, “New WHO and World Bank Group Report Shows that 400 Million Do Not Have Access to Essential Health Services and 6% of Population Tipped into or Pushed Further into Extreme Poverty because of Health Spending”, about says it all. Or does it? Certainly, it summarizes the core information provided by that study, and that is pretty bad. Even in a world whose population this year reached 7 billion that is a big number (nearly 6%), and remember that it is talking about “…essential health services—including family planning, antenatal care, skilled birth attendance, child immunization, antiretroviral therapy, tuberculosis treatment, and access to clean water and sanitation.” This is not coronary artery bypass surgery (as essential as that seems to those of us who need it), or knee replacement (which may make it possible for us to walk with less pain), or even tight control of our diabetes (possibly less prevalent in populations that are chronically malnourished), still less entirely elective care.

We are talking about access to clean water and sanitation. We are talking about the fact that the greatest cause of death in the world is water and that most of those deaths are in children. We are talking about the absence of the most fundamental aspects of access to health, not to mention health care and medical care.  While not a focus of the World Bank report, in many places war makes it worse, adding to the lack of basic services an extraordinary need for major medical care. In his New York Times Op-Ed piece of June 21, 2015, Nicholas Kristof describes the chilling war being waged by the government of Sudan against its own people in the Nuba Mountains, with daily bombings of civilians. He describes the deaths and maiming of children, and the inadequacy of even the most committed physicians to help in the atrocious conditions that exist there. An 8-year old boy, who had just lost several siblings to the bombing, “showed extraordinary courage,” the lone doctor at the hospital remembers, “but he would scream every day from pain as his dressings were changed.” While he “persevered for weeks”, “flies were laying eggs in his wounds, and soon the burns were crawling with maggots. Dr. Catena says that he would cut out the maggots, and the next day more would return.”

Yes, most of these 400 million are not in the US, are in developing (a euphemism, perhaps) countries. But in the US there is great need also; every day in our cities we see people who have not had access to TB or HIV treatment, who have delayed care because they are uninsured and cannot afford the cost, until they are so sick that their treatment costs far more than it otherwise would have. We see women who do not come for antenatal care until very late in their pregnancies if at all, missing the chance to discover and treat relatively minor problems until they become major. Fortunately, it is uncommon in the US for them to not receive “skilled birth attendance” since the law requires hospitals to provide care when women come in in labor, but they often appear with no records of whatever prenatal care they may have had. An excellent post on the blog of Medical Care Section of the American Public Health Association (unfortunately, access is limited to APHA members), “For Medicaid enrollees, a choice: PCP or emergency department?”, by Sandhya V. Shimoga, describes the problems that Medicaid patients, particularly those newly covered by Medicaid expansion in those states that have done so, in finding primary care providers; they continue to have to use the ED instead, often (again) with conditions far worse than they would have otherwise had. This, of course, does not count the largely insured people in the US who elect not to immunize their own children, secure in the knowledge that most other people are and that they will have access to care if anything does go wrong. Which it often, by the way, does.

And then there are states like mine, Kansas, that have chosen not to expand Medicaid, so that people similar to those Shimoga describes in Oregon and California do not even have a choice. The people of this state, once proud of its education and health care, have seen their rate of uninsurance increase relative to the states which have expanded Medicaid (Kansas only state to increase number of uninsured: A how NOT to do it strategy, August 9, 2014). The “solution” backed by the Republican Party and state governors such as Kansas’ Governor Brownback, is to further decrease the number of insured people by suing on a wording issue in the Affordable Care Act (ACA, “Obamacare”) that might invalidate the federally-run insurance exchanges which have allowed low-income-but-not-desperately-poor people in states like Kansas to gain insurance coverage.

This is a bold strategy, likely to work as well as Governor Brownback’s experiment in reducing taxes on the wealthy and businesses in 2012, which left the state with an $800 million budget deficit this year (on a budget of only about $8 billion). Half was replaced with one-time funds (eg, raiding the state highway fund) and the other half, after a marathon legislative session that ended a month late, with the largest tax increase in state history. However, these were all regressive taxes, mainly a sales tax increase, that hurts the poor and middle class; the 2012 cuts stayed in place for the wealthy, so I guess in that sense it did work. Business pays less tax, and if you own your business (say, self-employed lawyers or doctors) you pay no state income tax although your employees do. Kansas spends less now than neighboring Nebraska, which has 2/3 as many people. Now if we can only get rid of those federally-sponsored exchange so even more people will be uninsured…

The World Bank report calls for universal health coverage. “The world's most disadvantaged people are missing out on even the most basic services," says one official, who adds that a “... commitment to equity is at the heart of universal health coverage.” The report said that 17% of people were pushed into poverty (<$2/day) and 6% into “extreme poverty” (<$1.25/day) by the cost of emergency health care. Few Americans make anywhere near that little, but the cost of living, and of health care, is much higher and the same trend exists here; medical expenses are the largest cause of personal bankruptcy (see Fox Business’ 2014 report).

“As more countries make commitments to universal health coverage, one of the major challenges they face is how to track progress,” says another World Bank official, commenting on the study. Of course, if a country, such as the US, does NOT make a commitment to universal health coverage, this is not a problem.

Except, of course, for the people without health care.